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The Continuing Spread of HIV/AIDS in the Southern US
Fourth, HIV-infected African-Americans are more likely to be tested late in poverty) in the country, 78% are in the South (US Census Bureau 2004).
the course of disease
8
and are less likely to initiate and/or adhere to Many HIV-infected southerners rely on public funding such as Medicaid
effective therapy.
9
These factors may also result in more rapid progression for HIV medical care. However, some low-income HIV-infected individuals
to AIDS among those who are HIV-infected. Even controlling for the are ineligible until their medical expenses meet eligibility requirements or
proportion of the black population, being a southern state is an their HIV disease progresses to meet the Social Security Administration’s
independent predictor of a higher recent growth rate of the AIDS definition of disability,
16
and they are less likely to receive optimal care
epidemic.
3
This may suggest that there are other risk factors for an from the underfunded Medicaid programs in the South than in other parts
AIDS epidemic in the South, and being a southern state might be a marker of the US. Southern states may be more likely to receive some federal
for these risks. There is a suggestion that HIV-infected persons in the South funds to meet their unmet financial needs, such as the Ryan White
receive poor care and treatment, and therefore they would be likely to Comprehensive AIDS Resources Emergency (CARE) Act and the AIDS Drug
develop AIDS rapidly.
10
Potent antiretroviral therapy (ART) could also reduce Assistance Program, but most federal funds for HIV medical care are
HIV viremia and the infectiousness of infected persons, such that access to allocated to locales based on where a person was diagnosed; therefore,
and use of potent ART would decrease sexual transmission of HIV if HIV-infected individuals who are migrants to the South further reduce the
infected persons did not increase their risk-taking behaviors due per capita share of already sparse financial resources. Compared with
to complacency from the ART prevention gains. We have not found the West and Northeast, the South has a more limited health
comprehensive recent data regarding the utilization of ART across regions infrastructure and fewer venues that can provide comprehensive care for
of the US. An earlier national survey in 1996 found that persons in the AIDS patients. Southern states also have larger proportion of rural
South had lower rates (though not statistically significant) of using residents living with HIV/AIDS, and about two-thirds of rural cases in the
protease inhibitor and non-nucleoside reverse transcriptase inhibitor US live in the South. Furthermore, there are fewer physicians in the rural
therapy compared with the surveyed persons in the rest of the country.
11
southern region. For example, in 2001 in northeastern non-metropolitan
statistical areas (non-MSAs), the median number of physicians per
The Effects of Migration 100,000 population was 85.6 (range: 57.3–125.1), against only 55
An increase in HIV/AIDS in the South may also result from cross-regional (range: 42.2–70.5) in southern non-MSAs.
5
The reliance of rural residents
migration
12,13
and facilitation of HIV incidence through a higher prevalence on urban clinics introduces additional potential barriers including
of sexually transmitted diseases (STDs). An analysis of 760 HIV-infected transportation, time off work, lost wages, and childcare.
persons in non-urban areas of Alabama and Mississippi found that 30%
moved after testing HIV-positive. Many reported being infected in A Cultural Legacy?
metropolitan cities in the Northeast or the West and moving to the South In the South, there are fewer black physicians who provide AIDS care than
for family and social support after discovering their HIV status.
13
These are needed, and white doctors may either lack cultural sensitivity or be
infected migrants may pose risks of transmission to local residents in the otherwise in an unfavorable position to win the trust of black patients,
South. Many southern states reported persistently high rates of STDs given the legacy of segregation. In the South, the Tuskegee Syphilis Study
disproportionately affecting blacks and the poor, both inflammatory (e.g. and a failure to welcome blacks into segregated healthcare settings
gonorrhea and chlamydia) and ulcerogenic (e.g. syphilis and herpes continues to have an impact on the willingness of African-Americans to
simplex type 2).
14,15
For example, the rate of gonorrhea was 28 times seek care. A prevalent myth is that HIV was developed by the US
higher in blacks than in whites in 2001, and syphilis 24 times higher.
14,15
government for the purpose of racial genocide. All of these barriers may,
High rates of STDs may be a marker for risky sexual behaviors that individually or collectively, lead to delayed uptake of optimal care or affect
could facilitate transmission of HIV, and STDs themselves could also HIV treatment adherence and outcome.
biologically facilitate acquisition and transmission of HIV.
In summary, the HIV/AIDS epidemic in the southern US merits special
Access to Healthcare intervention and concern. The growth of the methamphetamine epidemic
The South faces significant challenges in addressing the HIV/AIDS has resulted in increased sexual risk-taking, as has been the case with
epidemic because of high levels of poverty, lack of health insurance, cocaine use. Challenges in rural areas among African-Americans, MSM, and
relatively poor health infrastructures, high proportions of rural residents, women whose risk may be derived less from their own high-risk behaviors
the legacy of racial segregation, and cultural insensitivity.
16–18
The South is than from the behaviors of their husbands or partners, must all be
poorer than other regions; for example, of the 229 counties with the addressed with both community-based prevention programs and expanded
highest poverty rates (>25% of all residents meeting census definitions of access to HIV-therapy opportunities. ■
1. Agee BS, Funkhouser E, Roseman JM, et al., AIDS Care, 7. Thomas JC, Sex Transm Dis, 2006;33(Sl):S6–10. 2006;18(S1):S51–8.
2006;18(S1):S51–8. 8. Wortley PM, Chu SY, Diaz T, et al., AIDS, 1995;9(5):487–92. 14. Farley TA, Sex Transm Dis, 2006;33(Suppl.):S58–64.
2. Centers for Disease Control and Prevention, HIV/AIDS Surveillance 9. Gebo KA, Fleishman JA, Conviser R, et al., J Acquir Immune Defic 15. Centers for Disease Control and Prevention, Sexually Transmitted
Report,Volume 17, Revised Edition, 2007. Syndr, 2005;38(1):96–103. Disease Surveillance, 2002 and 2003, Atlanta: US Department of
3. Qian HZ, Taylor RD, Fawal HJ, Vermund SH, AIDS Care, 10. Moon T, Vermund SH, Tong TC, Holmberg SD, J Acquir Immune Health and Human Services, 2002 and 2003.
2006;18(S1):S6–9. Defic Syndr, 2001;28(3):279–81. 16. Krawczyk CS, Funkhouser E, Kilby JM, Vermund SH, AIDS Care,
4. Fleming PL, Lansky A, Lee LM, Nakashima AK, Sex Transm Dis, 11. Shapiro MF, Morton SC, McCaffrey DF, et al., JAMA, 1999;281(24): 2006;18(S1):S35–44.
2006;33(Supp.):S32–8. 2305–15. 17. Berman SM, Cohen MS, Sex Transm Dis, 2006;33(Supp.):S50–57.
5. McKinney MM, J Rural Health, 2002;18: 455–66. 12. Cohn SE, Klein JD, Mohr JE, et al., South Med J, 1994;87(6): 18. Reif S, Golin CE, Smith SR, AIDS Care, 2005, 17(5):558–65.
6. Austin J, Irwin J, ., Belmont, CA: Wadsworth/Thompson Learning, 599–606.
2001. 13. Agee BS, Funkhouser E, Roseman JM, et al., AIDS Care;
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